Palpation Auscultation CLINICAL SKILLS

Clinical skill 4. Thyroid gland physical examination

a. Inspect the neck for the thyroid gland

Tip the patient’s head back a bit. Using tangential lighting derected downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage for the gland. Goiter is a general term for an enlarged thyroid gland. Ask the patient to sip some water and to extend the neck again and swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetri The thyroid cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then fall to their resting positions.

b. Palpation

Steps for palpating the thyroid gland: - Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles. - Place the fingers of both hands on the patient’s neck so that your index fingers are just below the cricoid cartilage - Ask the patient to sip and swallow water as before. Feel the thyroid isthmus rising up under your finger pads. It is often but not always palpable. - Displace the trachea to the right with the fingers of the left hand; with the right hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sterbomastoid. Find the lateral margin. In similar fashion, examine the left lobe. The lobe are somewhat harder to feel than the isthmus, so practice is needed. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb and feels somewhat rubbery. - Note the size, shape, and consistency of the gland and identify any nodules or tenderness. Soft in Grave’s disease Firm in Hashimoto’s thyroiditis, malignancy Benign and malignant nodules Tenderness in thyroiditis. Note: The thyroid gland is usually easier to feel in a long slender neck than in a short stocky one. In shorter necks, added extension of the neck may help. In some persons, however, the thyroid gland is partially wholly substernal and not amenable to physical examination. Udayana University Departement of Medicine Education, DME 34 Learning task: Check your body mass index, waist circumference and waist to hip ratio, and interpretate the result.

c. Auscultation

If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of noncardiac origin. A localized systolic or continuous bruit may be heard in hyperthyroidism. Clinical skill 5. Laboratory result interpretation Case 1. Female 15 years old came to hospital with decrease of consciousness. One day before admission, she through up everything she ate and had a very bad pain in her stomach. Since this last one month, she was very weak and could not do her daily activity very well. She had never been diagnosed with any specific illness before. Laboratory result: Blood sugar random 645 mgdL Urinalysis keton +3 Blood gas analysis pH 7.12 normal: 7.35-7.45 pO2 97 normal: 80 – 105 HCO3 - 3.00 mEqL normal: 21-30 Case 2. Male 44 years old came to outpatient clinic with an acute swelling and pain of his thyroid nodule. The first laboratory result was: TSHs 0.023 uIUml normal range: 0.25 – 5 uIUml FT4 20.51 ugdl normal range: 5.13 – 14.06 ugdl The second laboratory result after 3 months was: TSHs 7.23 uIUml normal range: 0.25 – 5 uIUml FT4 2.33. ugdl normal range: 5.13 – 14.06 ugdl Udayana University Departement of Medicine Education, DME 35 Learning task: Try the physical examination of your friend’s thyroid gland and note the size, shape, and consistency of the gland and identify any nodules or tenderness. Learning task: 1. What is the diagnosis of this case? 2. After insert the intravenous line and rehidration, you decide to give an insulin therapy. Is there any laboratory data that you need before administering insulin in this patient? Learning task: 1. What is the meaning of the first result and the second result? 2. Why this patient come up with the different result after 3 months? 3. What do you think the diagnosis of this case? Case 3. Female 22 years old, came to outpatient clinic with chief complain palpitation, nervous, and decrease of body weight. Her eyes look bigger than before since last 6 months. Laboratory result: TSHs 0.005 uIUml normal range: 0.25 – 5 uIUml FT4 12.51 ugdl normal range: 5.13 – 14.06 ugdl Udayana University Departement of Medicine Education, DME 36 Learning task: 1. What is the interpretation of laboratory finding? 2. What other laboratory examination do you suggest? Student Standard References: Basic Clinical Endocrinology, 9 th ed, Lange Medical Publication Additional Recommended Reading 1. Essential Clinical Anatomy, 2 nd ed. Lippincott Williams Wilkins, Philadelphia. 2002. 2. Fawcett DW, Jenish RP : Bloom and Fawcett`s Concise Histology, 2 nd ed, London, Arnold, 2002. p. 220-221, 251-266. 3. Guyton A. C and Jhon E. Hall Textbook of Medical Physiology:Page: 836-914 4. Harper, 25 ed.p.451-626 5. Baynes J; Dominiczak Marek H. Medical Biochemistry.1999. chapter 12, chapter 17, and chapter 23 page 297-304 6. Robbins Basic Phatology, 7 ed, 2003.p.221-225 7. Henry JB; Alexander ; Eng C D. Evaluation of Endocrine function In : Henry JB Ed. Clinical Diagnosis and Management by Laboratory Method. 19 th Ed.1996. p.322-373 8. Gartner LP, Hiatt JL : Color Text Book of Histology, 2 nd ed, Philadelphia, W.B. Saunders, 2001,p. 301-324. 9. Wales J.K H, 1996. Pediatric endocrinology and growth: Abnormal Genitalia; 99-116 10. Styne DM, 2004. Handbooks in Pediatric endocrinology: Disorders of sexual differentiation; 134-158 Reference Clinical Skills 1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 8 th eds. Lippincott William Wilkins. Philadelpia, 2003. 2. American Diabetes Association. Clinical Practice Recommendations 2015. Diabetes Care 2015 3. The Asia-Pacific perspective: Redefining Obesity and its treatment, 2000. Udayana University Departement of Medicine Education, DME 37

15. REFFERENCES